Medical Faculty Certificate Application Checklist
All applications for Medical Faculty Certificates are submitted to the Dean’s Office (Brian Berryman / 273-5077) for review and processing.
PLEASE NOTE: THERE IS NOW AN APPLICATION FORM FOR THE MEDICAL FACULTY CERTIFICATE;BELOW ITEMS ARE REQUIRED IN ADDITION TO APPLICATION
_____ **Check ($500 application fee/$429 licensure fee,) (can be 1 check made payable to the Florida Board of Medicine) There is also a $48 fingerprint processing fee if fingerprints have not yet been taken. Additionally, the Board is required to collect on intial application, the Florida Birth-Related Neurological Injury Compensation Assessment (NICA) Non-Participating Physician – $250 ($1,227 total)
_____ **Proper/legible copy (see helpful hints) of medical school diploma. Medical school verificaton is also required; verificaton form is included in MFC application.
_____ Proper/legible copy(s) of internship/residency certificates. If certificate not available, there must be letter from program director certifying successful completion
_____ (2) Letters of Recommendation addressed to: Florida Board of Medicine (letters must be less than 6 months old)
_____ Certified transcripts from all medical schools/certified transcripts if needed (must be translated be certified translator if language other than English or Latin)
_____ Written verification from state board of any licenses (active or inactive). Letters must be on state letterhead with state seal and original authorized signature; be aware that many states now charge a fee for this
_____ **Letter from physician stating all states licensed in (active or inactive)
_____ If applicant has been in military, Florida Board requires a copy of discharge papers.
_____ **A recent photograph (must be less than 6 months old/not Polaroid)
_____ **Date of birth, place of birth and Social Security number
_____ Any name change involved (marriage, divorce) must include certified documents (marriage certificate, divorce decree, etc.)
_____ A recent Curriculum Vitae (CV)
_____ Financial responsibility and confirmation of completion of Continuing Medical Education form. Please note that effective July 1, 2006, applicants for MFC’s are no longer required to show proof of a course in HIV/AIDS or Domestic Violence as part of the initial licensure process, but are required to have a CME course in the Prevention of Medical Errors prior to issuance of a MFC. (Form is included on web as part of MFC application)
_____ A properly executed fingerprint card must be submitted with application (Blank fingerprint cards are available in the Office of Administration Services)
_____ Request to National Practitioner Data Bank and Healthcare Integrity and Protection Databank for a self query,which then must be forwarded to Board (fee is charged for this information). For additional information visit web-site at http://www.npdb-hipdb.hrsa.gov/ or by phone (800) 767-6732, Box 10832, Chantilly VA 22021
_____ **Request to AMA for Profile Form(must be requested/signed by physician) (fee is charged for this information)
- Print the form from the web and fill out
** Note: minimum documents required to initially submit MFC application to Dean’s Office (Brian Berryman / 273-5077)
MEDICAL FACULTY CERTIFICATE RENEWAL APPLICATION CHECK LIST
_____ Letter of request from Department Chair addressed to Dean explaining circumstances
_____ Check ($391 renewal) (includes $26 background check fee, FDLE check and $5.00 unlicensed activity fee). Check is made payable to the Florida Board of Medicine.
_____ Written verification from state board of any licenses (active or inactive/) Note: at least one must remain active). Letters must be on state letterhead with state seal and original authorized signature; be aware that many states now charge a fee for this ( list of state boards included )
_____ Florida Board requires check/search with the Florida Department of Law Enforcement for renewals
_____ Financial Responsibility and confirmation of completion of Continuing Medical Education
- Print the form from the web and fill out: PDF
_____ Florida Board requires a Medicaid Program Questionnaire
_____ A recent Curriculum Vitae (CV)